Yannik Kalbas

Purpose: Blunt abdominal trauma (BAT) is common in polytrauma patients. Emergency surgery is required for haemodynamically significant solid organ injury and intra-abdominal hollow organ injury. The effect of time to surgery on outcomes in patients requiring emergency laparotomy remains uncertain. Materials & methods: Adult polytrauma patients (ISS > 16) who underwent emergency laparotomy for blunt abdominal trauma between 1996 and 2020 from a trauma registry of a single level one trauma centre were included. Patients were divided into two groups based on the time elapsed from admission to emergency laparotomy: “Super Early” (≤ 60 min) and “Early” (60–180 min). Length of stay (LOS), intensive care unit (ICU)-LOS, ventilation time, re-look operations and mortality were assessed. Adjusted logistic regression was used to determine the independent predictive parameters, including timing of surgery, for mortality. Results: The study included 190 polytrauma patients with concomitant blunt abdominal trauma (mean age 42 years (± 17), median ISS of 36 (IQR: 19)). There were 95 patients in each group. Patients in the “Super Early” group had a compromised haemodynamic status and a higher ISS. Liver injury and serous membrane injury were more common in the super early group. The mortality rate was significantly higher in the “Super Early” group (51.6%) compared to the “Early” group (26.3%) ( p < 0.001). Death due to haemorrhagic shock was significantly more frequent in the “Super Early” group (36.8%) compared to the “Early” group (13.7%) ( p < 0.001). A regression model was adjusted to determine the independent predictors of mortality. Time to emergency laparotomy was not an independent predictor of mortality. However, increased ISS (OR = 1.04, p = 0.049), age (OR = 1.03, p = 0.037) and decreased systolic blood pressure (OR = 0.98, p = 0.025) were found to be significant predictors of mortality. Conclusion: The timing of surgery showed no independent association with mortality as long as an emergency laparotomy was performed within 3 h of admission. The data suggests that patient-specific characteristics, injury severity and clinical status are more important for survival than the timing of an early emergency laparotomy. Future research should focus on determining the role of delayed laparotomy on outcomes in specific subgroups of patients.

Introduction: Unstable pelvic ring injuries in polytrauma patients remain among the most lethal injury patterns, largely due to hemorrhage and the physiological burden of staged surgical management. While temporary external fixation is widely used as part of damage-control strategies, early definitive posterior stabilization using percutaneous sacroiliac “rescue screws” may provide sufficient mechanical stability while reducing cumulative operative stress. However, comparative clinical data supporting this approach remain scarce. This study investigates operative strategies, timing, and early outcomes in a consecutive cohort of severely injured patients with unstable pelvic ring fractures treated at a Level-1 trauma center. Methods: We performed a retrospective cohort study including patients aged ≥ 16 years with high-energy unstable pelvic ring injuries (Young and Burgess APC II–III, LC III, combined mechanism, and vertical shear) and an Injury Severity Score (ISS) > 16. Demographic data, injury severity, hemodynamic status on admission, operative strategies, number of surgical procedures, and length of hospital stay were analyzed. Outcomes were compared between early definitive posterior fixation and temporary external fixation. Statistical significance was defined as p < 0.05. Results: Seventy-two patients were included (mean age 43.6 ± 17.3 years; 72.2% male), reflecting a severely injured cohort with a mean ISS of 30.4 ± 10.6; 30.6% presented with hemodynamic shock on admission. Early definitive posterior stabilization without prior temporary external fixation was achieved in n = 63 patients (87.5%). Temporary external fixation was required in n = 9 patients (12.5%), who demonstrated significantly greater injury severity, including higher ISS (41.0 ± 11.3 vs. 28.9 ± 9.8), higher NISS (45.7 ± 12.5 vs. 30.8 ± 10.4), and a higher incidence of shock on admission (44.4 versus. 28.6%). Compared with early definitive fixation, external fixation was associated with a substantially higher operative burden (2.31 ± 0.85 vs. 1.41 ± 0.67 procedures) and prolonged hospitalization (31.9 ± 30.2 vs. 23.4 ± 25.3 days). Radiographic reduction quality did not differ between the groups, with a mean residual sacroiliac joint diastasis of 4.14 ± 1.21 mm in the SDS group and 4.11 ± 0.71 mm in the ExFix group; according to the Matta and Saucedo criteria, all reductions in both groups were graded as anatomic or nearly anatomic. Importantly, early posterior fixation using percutaneous sacroiliac rescue screws was not associated with an increase in early fixation-related complications, even in initially unstable patients. Conclusion: In a Level-1 trauma setting, early definitive posterior stabilization using percutaneous sacroiliac rescue screws is feasible and safe in most patients with unstable pelvic ring injuries. Compared with traditional staged management using temporary external fixation, this strategy was associated with a reduced cumulative operative burden and a shorter hospital length of stay without compromising early safety. Given the small number of patients managed with external fixation, these comparative findings should be interpreted with caution. External fixation should be reserved for select patients with extreme injury severity or specific limiting factors for safe definitive surgery. These findings question the routine use of staged damage-control strategies and support early posterior definitive fixation as a component of modern pelvic trauma care.

Background: Rapid identification of vascular compromise remains a clinical challenge in the acute trauma setting. Conventional diagnostic tools such as CT angiography (CTA) and Doppler-ultrasound might provide decent anatomical and functional assessment. However, they are limited by ionizing radiation, contrast exposure or time requirements. Although not validated, infrared thermography (IRT) might offer a non-invasive alternative capable of detecting surface temperature asymmetries that may reflect underlying perfusion deficits. This study aimed to evaluate the feasibility of thermographic imaging in detecting vascular lesions. Methods: As part of a porcine polytrauma model ( n = 28), vascular lesion of the right femoral artery was defined as a ≥ 50% diameter reduction on CTA. Temperature differences between both extremities were measured using infrared thermography. SDCT based iodine concentrations distal to the stenosis were quantified to assess perfusion changes. Correlation and regression analyses were performed between stenosis degree, temperature difference, and tissue iodine uptake. Results: Six animals fulfilled the criteria for relevant vascular compromise. This resulted in a mean vessel diameter reduction behind the lesion of 68% ±18%. The vascular lesion group demonstrated a mean inter-limb temperature difference of 6.93 °C ± 1.78 °C compared to 0.71 °C ± 1.27 °C in the non-lesion group ( p < 0.001). A strong positive correlation was found between diameter-based stenosis and temperature difference ( r = 0.785, p < 0.001), as well as between diameter reduction and iodine uptake ( r = 0.801, p < 0.001). ROC analysis of temperature difference for detecting vascular lesion yielded an AUC of 0.992 (95% CI 0.970–1.000, p < 0.001) with 100% sensitivity and 95.2% specificity at a 3 °C threshold. Conclusion: Thermographic temperature differences showed excellent diagnostic performance in detecting an acute vascular lesion in a large animal model. The strong correlation between SDCT iodine uptake and both anatomical stenosis and surface temperature suggests that iodine concentration is a valid quantitative surrogate for perfusion. In conclusion, infrared thermography might represent a viable alternative for detection of acute vascular occlusion.

Background/Objectives: The growing elderly population and concomitant increase in physical activity of older adults has led to a growing number of seriously injured elderly patients. The aim of this retrospective cohort study was to investigate the influence of the leading region of injury in severely injured patients on the risk of mortality in different age groups, with focus on elderly patients. Methods: Data from the TraumaRegister DGU^® from 2015 to 2020 were analyzed, including severely injured patients admitted to Swiss, German and Austrian trauma centers. Inclusion criteria were a minimum age of 18 years and an Abbreviated Injury Scale (AIS) score of three or higher in at least one of the body regions. Descriptive analysis and odds ratios for mortality derived from multivariable analysis were calculated, stratified by age and leading region of injury. Results: Out of 213,216 patients, 98,481 met the inclusion criteria. Mortality increased from 6.9% in the control group (18–54 years) to a maximum of 35.9% in the 90+ age group. Leading head injuries had a mortality rate of 22%. The odds ratio for the risk of mortality increased with age and reached a maximum value of 17.0 in the 90+ age group. However, the increase in risk of mortality for leading head injury with increasing age was lower than in the other regions, with an OR of 11.7 in the 90+ age group. In contrast, the group with a leading thoracic injury increased to an OR of 22.5, abdomen to an OR of 75.2 and extremities to an OR of 28.7. Conclusions: The risk of mortality from traumatic head injury is less pronounced in elderly people compared to other injury regions. Our data suggests that traditional scoring systems like the AIS might not display nuances of different injury severities in different age groups, especially for head injuries caused by low-energy trauma and therefore should be reevaluated.

Background: Gustilo-Anderson type III B/C open tibial fractures are among the most complex and high-risk injuries in trauma care. Their management demands a multidisciplinary approach, and early intervention is critical. While early debridement has been established as essential, the optimal timing for definitive orthoplastic coverage remains less clearly defined. Objective: To evaluate whether early orthoplastic coverage reduces the risk of fracture-related infections (FRIs) and complication rates compared to late coverage in type III B/C open tibial fractures. Methods: We conducted a PRISMA-compliant systematic review and meta-analysis of studies comparing early versus late orthoplastic treatment in patients with Gustilo-Anderson III B/C open tibial fractures. Databases included PubMed and EMBASE. Primary outcome was FRI; secondary outcomes included amputation, non-union, and revision surgery rates. Risk of bias was assessed using the Newcastle-Ottawa Scale. Results: Of 3746 studies screened, five studies with a total of 454 patients met the inclusion criteria. Cutoff for early vs. late treatment was defined variably across studies (either within 72–168 h). Meta-analysis showed that early treatment significantly reduced the odds of infection (OR: 0.34; 95% CI: 0.23–0.52; p < 0.001) compared to late treatment. Subgroup analyses confirmed consistent benefits regardless of timing cutoffs or surgical approach (“fix and flap” vs. staged). While trends suggested reduced rates of amputation and non-union with early treatment, these did not reach statistical significance. Conclusion: Early orthoplastic coverage significantly reduces FRI in patients with Gustilo-Anderson III B/C open tibial fractures. While secondary outcomes showed positive trends, further high-quality prospective studies are needed.

Background: Hemorrhagic shock (HS) is a major risk factor for mortality and complications after severe trauma. Yet, complex mechanisms on a cellular and physiological level are still not fully understood, Metabolomics offers a powerful tool to unravel these complex biochemical alterations following HS and trauma (T). However, no systematic synthesis of metabolomic findings in in standardized translational animal models of HS and HS + T exists to date. Objectives: To systematically review and compare metabolomic alterations in animal models of isolated hemorrhagic shock and hemorrhagic shock with trauma, highlighting key metabolic pathways and their modulation by resuscitation strategies. Methods: We performed a systematic review on Pubmed and EMBASE to identify relevant metabolomic changes measured in with mass spectrometry in translational animal models following HS and HS + T. Studies were categorized into two groups in regard to our main objective: Isolated HS and HS + T. Key metabolite changes were extracted and analyzed qualitatively across seven major metabolic domains: energy, amino acids, purines, arginine/urea cycle, lipids, sulfur/creatine, and redox balance. Results: Overall, 25 studies were included in our analysis. HS and HS + T both exhibited consistent changes in lactate (↑), succinate (↑), glutamine (↑), and acylcarnitines (↑), indicating hypoxia-driven glycolysis, mitochondrial dysfunction, and enhanced proteolysis. HS + T models displayed more pronounced alterations in branched-chain amino acids, purine catabolites (urate, inosine), and markers of oxidative stress. ATP depletion and glutathione imbalance were common, particularly in the trauma group. Plasma resuscitation partially corrected several abnormalities, especially in redox, purine, and glutamine pathways, compared to saline. Conclusions: Metabolic responses to hemorrhagic shock are reproducible across animal models and are amplified by the presence of trauma. Trauma accentuates proteolysis, oxidative stress, and nucleotide turnover. Plasma-based resuscitation appears superior to crystalloid in correcting these derangements. These findings support the exploration of targeted metabolic therapies and advocate for metabolomics-informed resuscitation strategies in trauma care.

Introduction: The timing of definitive fracture care in polytrauma patients remains a complex topic, especially in the presence of concomitant intracranial injuries, which often dictate surgical priorities. The International MultidisciPlinAry Consensus panel on polyTrauma (IMPACT) recently proposed recommendations on the timing of surgical interventions in polytrauma patients with competing priorities and identified some gaps in evidence. The aim of this study is to provide a systematic review of the scientific evidence on the timing of fracture fixation in patients with traumatic brain injuries (TBI). Material & methods: A systematic review on MEDLINE and EMBASE was performed, including original articles published between 2000 and 2024, comparing the outcomes of early (≤ 24 h) versus late (> 24 h) definitive fracture fixation in polytrauma patients with TBI. Demographic data, overall injury severity, and TBI severity of the respective cohorts were taken into consideration for qualitative analysis. Additionally, complication rates and outcomes were assessed. Results: A total of 9782 studies were identified. After applying the inclusion and exclusion criteria, 7 studies were finally included. Overall, significant heterogeneity was observed in the selection criteria, with some studies focusing on more severe and others on milder TBI, using different criteria. Overall, most studies provide evidence that early fracture fixation in patients with mild TBI might be beneficial for patients’ outcomes. Conclusions: Early definitive fracture fixation within 24 h should be attempted in polytrauma patients with concomitant mild TBI under specific conditions, which were previously defined by the IMPACT group. Furthermore, current evidence suggests that this approach is both safe and beneficial in a carefully selected patient population. In cases of moderate and severe TBI, decision-making is usually more difficult and complex, often requiring it to be individualized. However, we identified several gaps in the existing literature, particularly with regard to the heterogeneity of the available studies in terms of inclusion criteria, injury morphologies and investigated outcome parameters. Prospective or detailed registry studies are required to obtain further insight into this relevant topic.

Background: Assessment of pelvic ring injuries in the pre-clinical and trauma bay setting represents a challenge for the treating trauma team. The objective of the present project was to conduct a pre-clinical trial to investigate the feasibility and accuracy of ultrasound (US) guided assessment of symphyseal diastasis, of cadavers with pelvic ring injuries. Methods: This is a prospective, anatomical, interventional and radiological cadaveric laboratory investigation. Cadavers were prepared with a pelvic ring injury (symphyseal diastasis). Eleven trauma surgeons performed an ultrasound-guided assessment of the symphyseal diastasis. The intervention was performed in four formalin-fixes cadavers. One served as the control and the other were prepared to have a set of standardized symphysis diastasis. The diastasis was grouped into “below 2.5 cm” and “above 2.5 cm”. Trauma surgeons were blinded to the symphysis diastasis and performed an ultrasound-guided assessment of the anterior pelvic ring. Sensitivity and specificity analyses were performed. Results: The ultrasound measure of the control provided a sensitivity of 0.73 (95%CI 0.39 TO 0.94). The sensitivity of the ultrasound measure increased with increasing diastasis of the symphysis (Group above 2.5 cm 0.82, 95%CI 0.48 to 0.98). The highest sensitivity was measured in the dynamic assessment of the symphysis closure (0.91, 95%CI 0.59 to 1.0). Specificity was lowest in Group below 2.5 (0.73, 95%CI 0.39 to 0.94). Conclusion: Ultrasound-guided assessment of symphyseal diastasis is feasible and shows high diagnostic accuracy, especially for diastasis > 2.5 cm and during dynamic evaluation. Sensitivity and predictive values improved with larger displacements, while detection of smaller diastasis remained limited. These findings support the potential use of ultrasound as a rapid, non-invasive tool in early pelvic trauma assessment.